Monday, Jan 30, 2012, 8:00 am

Facing Maternity Care Gaps, Midwives Push for Birthing Justice

Email this article to a friend

your email

your name

recipient(s) email (comma separated)

message

captcha

Photo: Getty Images

As wondrous a phenomenon as childbirth is, we often view it as a form of medical purgatory--hours of drug-dampened agony under starched sheets and sterile lights. But more women today are thinking outside the box about labor. Home-based births have shot up in recent years. Advocates across the country have persuaded governments to broaden medical coverage for out-of-hospital birth services.

And in the shift toward more natural childbirth, midwives are at the forefront. Born of a movement to reclaim the childbirth experience from the medical establishment, today's professional midwives are a modern incarnation of an age-old vocation, defining themselves as an alternative to the hospital ward. Yet the workers who undertake this unique labor of labor long struggled for respect and equality under healthcare laws.

Midwife-assisted birth at home or at a birthing center--a facility specializing in childbirth and pregnancy care--allows many women with low-risk pregnancy to give birth safely without interventions like surgery. Advocates say this process provides a more holistic experience for a woman in a familiar setting, sans the medications or presence of a gaggle of strangers in scrubs.

Several states have policies that support some medical coverage for out-of-hospital birth, though access to midwife care remains inconsistent. National healthcare reform legislation marked a small breakthrough by allowing federal Medicaid coverage of midwife care at birthing centers. Legislation has been proposed to further expand Medicaid coverage of certified professional midwives.

Though the recent home-birth bump has been concentrated among white women, women of color have helped lead the push for comprehensive birthing options. In Texas, Mamas of Color Rising partnered with Texans for Midwifery on a Birth Justice campaign to broaden midwife care access, and recently persuaded health authorities to recognize licensed midwives as Medicaid providers. The aim is to let more low-income women to choose midwives for prenatal care or delivery. The group wrote to the state's Health and Human Services Commission:

We believe that equity in birthing options is both a matter of social justice and empowerment for birthing women, such access also leads to improved pre-natal, post-natal, and maternal outcomes for mothers and babies that can have long-lasting positives effects.

A midwifery renaissance could be a societal response to glaring inequities in maternity and infant health. Various studies suggest conventional maternity care--in which interventions like cesarean sections are common--poses huge costs for the medical system but yields relatively poor outcomes for families and communities. Maternal mortality rates remain disturbingly high, especially among black women--reflecting segregation across the healthcare system.

As part of the maternity care workforce, professional midwives could help fill the need for more community-oriented birthing options, providing relatively low-cost and effective care outside the hospital setting.

Executive director of the National Association of Certified Professional Midwives Mary Lawlor, who practices midwifery in New Hampshire and Vermont, told In These Times that in response to gaps in the healthcare workforce, certified professional midwives “go out into underserved communities, where the women live, where there aren't other providers, and provide community-based care for them."

The nascent midwifery resurgence renews the concept of women as pillars of both sides of the birthing process, with midwives and mothers working together intuitively and intimately--in sharp contrast to technology-based medicine that sharpens the boundary between doctor and patient.

But changing the culture of birth takes time. Under Vermont's new policy mandating insurance coverage for home births, for example, some midwives say they’ve had trouble obtaining insurance payments, particularly from Blue Cross. According to Burlington Free Press, the company says it is following the mandate, but the sticking point seems to be requiring midwives to carry costly malpractice coverage. "Women are being forced to choose hospital births in order to have the cost of their births covered," Erin Ryan, a midwife based in Worcester, Vermont, told ITT. "These cost are double and some times triple of what a home birth would have cost."

Going forward, midwives face a greater challenge than bureaucratic bottlenecks: structural problems in the healthcare system stemming from racial, gender and socioeconomic disparities, which relegate some communities to lower standards of care. As Mamas of Color Rising states in its manifesto on birthing access:

Currently full choices in type of birthing is only accessible to wealthier women, women with private insurance or with the ability to pay out of pocket. Undocumented women, uninsured women and women on Medicaid have access to a hospital (usually highly medicalized birth) often with a doctor they have never met before.

Before childbirth became embedded in the hospital system, midwives anchored the personal connection at the heart of one the most sensitive experiences of a woman’s life. Now, as care providers and as mothers-to-be, women are slowly reshaping the system to fit their needs and desires.

As with all reproductive justice struggles, from access to birth control to the right to choose, self-determination in childbirth is about putting social trust in the hands of women.

Michelle Chen is a contributing writer at In These Times and The Nation, a contributing editor at Dissent and a co-producer of the "Belabored" podcast. She studies history at the CUNY Graduate Center. She tweets at @meeshellchen.

Thank you Ms. Chen for a balanced piece on midwifery care and birth in the home or birth center for women with healthy low-risk pregnancies. The issues of safety have been well put to rest by several robust research studies around the world -- despite some who insist on including unplanned, unassisted home births and side-of-the-road births into their research -- and I appreciate you turning attention to the issue of disparities in maternal and infant health.
Mamas of Color Rising (http://mamasofcolorrising.wordpress.com) is doing such important work in raising a voice for justice in birth options for ALL women. Midwifery care can be an important part of the solution in reducing the rates of low birth weight and preterm labor for women of color -- rates that are double or triple the rates for white women. But first, all women need to have *access* to midwifery care, and this country still has a long way to go in that regard. The MAMA Campaign (http://www.mamacampaign.org) is working hard in Washington DC to make it happen.
I also want to call attention to the work that midwife Jennie Joseph is doing in Florida. "The JJ Way" model of care has *eliminated* disparities in preterm birth, and none of the mothers of color in her 2008 study had a baby of low birth weight. She is proving every day how her model of care can make a profound difference for low-income mamas and women of color. "The JJ Way" should be replicated as a best practice in cities across the country: http://jenniejoseph.com/node/16
Woman-centered care does not have to be an "alternative" form of the maternity care model in the U.S. It's not an either-or proposition. Women can receive attentive care during their pregnancies and births AND babies can be born safely outside of the hospital with trained and experienced midwives. It's time for ALL women to have access to this kind of care.Posted by Wendy Gordon, CPM, LM, MPH on 2012-03-29 09:09:31

This article does an excellent job of laying out some of the problems with maternity care in US. Unfortunately, no easy solutions have been found yet. We need to continue to work to increase access to quality health care for everyone, and especially to try to remove the health care disparity faced by people of color.
The proposed solution of increasing the number of women cared for by CPMs is a terrible idea.
Traditional midwives have always used the best available resources. It boggles the mind how CPMs can be lobbying (with professional lobbyists) for an increased role in health care. Their statistics are atrocious.
For low risk white women, they have 3 times the rate of perinatal death.
When this article references the CDC report saying that "homebirths have a lower risk profile", that means that women who choose to homebirth have no preexisting conditions. They are less likely than average to have a problem during or after birth. Why do homebirths have such bad rates?
The CPM lobbyists have refused to release their government funded records of 20,000 homebirths from the last decade.
http://ideas.time.com/2011/11/07/what-ricki-lake-doesnt-tell-you-about-homebirth/#disqus_thread
(Quick US midwifery primer:
CNM= certified nurse midwife, nursing school plus graduate degree in midwifery. Accountable to state nursing board.
CPM= certified professional midwife, (intentionally similar initials to above) self-certification based on portfolio of previously attended births. no anatomy/physiology or any courses required.
DEM= a "lay midwife" no education or certification)
In some areas of the country, there are not enough qualified care providers to go around. Women of color have significantly worse health outcomes than white women with comparable educational and financial levels.
One of the reasons why CPMs have so many more deaths is their inability to detect these preexisting conditions. Worse-- they claim that high blood pressure, gestational diabetes, and breech babies are all normal, natural conditions. They will tell you that "interventions" are what harm a mother and baby. They will tell you that less care is better. For women who are lucky, and have good outcomes, they are relieved to avoid all the "doctoring". They may feel triumphant and empowered. Unfortunately, some women are not so lucky. These women are the ones who need birth justice.
Ahh...but most CPMs don't carry malpractice insurance. "Everything will be fine. Your body was made to do this. Trust birth."
Because CPMs see so few births (averaging only a few hundred in a career), they see relatively few bad outcomes.
See the website 10centimeters.com for more information on positive birth advocacy. We can make maternity care better for everyone, without sacrificing the health or lives of our mothers and babies.
Posted by Not Science on 2012-02-07 12:46:58

About this Blog

"Working In These Times" is dedicated to providing independent and incisive coverage of the labor movement and the struggles of workers to obtain safe, healthy and just workplaces. more